Tag: films

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Is The Adult Abdominal Series Like Reading Tea Leaves?

abdominal series

At some point, most of you have probably come across the adult abdominal series, most often used for abdominal pain. You will see these exams performed in most Emergency Departments throughout the country. Typically, it includes a supine and upright or decubitus view of the abdomen.  At some institutions (like ours), it also consists of an upright chest x-ray. So, why do I want to bother discussing this imaging examination? It must have some issues, right? Well, of course!

So, what’s my beef with this exam? Well, I will go through all my issues with the study one by one. First of all, we will mull over the purpose of the imaging examination and its redundancies within the system.  Then, we will discuss precisely who may be ordering the study and why that has repercussions for the expense and overutilization of patient care. And finally, I will go into detail on how the ordering clinician uses the information (if they do at all!). All these points will show why I have negative feelings about the abdominal x-ray series. And, by the time you are done reading this, I believe you will too (assuming you don’t already!)

The Lowly Abdominal Series: Is It Being Used As It Should?

It may seem that every time a patient walks through the door with the complaint of abdominal pain, he gets an abdominal/pelvic CT scan and an abdominal series.  But, what is the point of getting an abdominal series if you already know that the patient is going to receive an abdominal CT scan for the same complaint? Can’t you get more information from a CT scan than an abdominal series? Well, the answer to that is clearly yes. That abdominal series becomes nothing more than redundant when you have already have a CT scan on the same patient.

Moreover, some clinicians say that they need it for triage. Well, in my experience, that is debatable as well. I can’t tell you how many times clinicians report that they will utilize the test to help them to determine if the patient needs a CT scan. But, if you think about that usage, it does not make sense as well. Why? Because the abdominal series is a notoriously insensitive and nonspecific test. I can think of gazillion times that I have seen a negative abdominal series in the setting of a rip-roaring positive abdominal/pelvic CT scan. Likewise, I see lots of positive tests that turned out to be nothing on the CT scan.

And, I have the data to back me up. Check this out. Here is a paper from the Radiology journal that gives the sensitivity of an abdominal series compared to a CT scan of 30%. Now, that statistic alone is pretty horrible. Translating that number into everyday English, it means that you will miss a positive abdominal diagnosis of about 70% of the time. Moreover, the specificity of a plain is around 56.5 percent. Or, that means that only just over about half the amount of time will the study give you the correct diagnosis. Not much of an improvement, huh? All this information begs the question, should we use this examination at all for triage for the complaint of general abdominal pain? Probably not!

Who Is Ordering This Study And Why It May Be A Problem

I don’t know about your ED, but at ours, ordering this study has almost become reflexive.  As soon as the patient walks through the door, a “midlevel” orders the study. Very rarely is the abdominal series used as initially intended, as a triage tool. And, using the abdominal films for triage is also likely not of much value, with such low sensitivity and specificity. It will misguide as often as it will send you in the correct direction.

So, why do clinicians utilize the study? I have a theory that it is no more than a crutch of tradition. It’s something that some clinicians hang onto because it was the test of choice in the past. And, the less you know, the more you cling onto things. Unfortunately, that leaves the less informed and educated staff to continue ordering the study.

And it is not a “benign test.” There is a significant radiation dose that accompanies it. Check out the list of radiation doses on this RSNA sponsored informational site. Each clinician needs to think about every test they order before they do so.  I have a feeling that is not happening!

Does It Help Managing Patient Care?

And, then finally, what happens when the clinicians receive the report from the lowly abdominal series? Is that information used? Well, I hope not! If you buy the previous studies, you will miss most diagnoses if you use it without a CT scan. Given the sensitivity and specificity, I believe the exam more likely increases the expense of healthcare because of false negatives and positives. The abdominal series is a prime example of a test that may cause the caring physician to order more tests than otherwise needed.

Abdominal Series For Abdominal Pain: Is It Like Reading Tea Leaves?

Based on the preponderance of evidence here, I believe it is probably not the best usage of our health care dollars. Sure, it is a quick and easy test.  But, quick and easy does not imply cost-effective and useful for patient care. We need to reconsider the use of this unhelpful exam, especially for the general complaint of abdominal pain. It does no more than lead our clinicians astray and increase the costs of health care for you and me.

 

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The Gestalt Versus Segmental Approach For Radiology Residents (Doximity Article)

gestalt

Ever watched an expert radiologist read a CT scan or an MRI? They gaze at a scan, digest the information in one fell swoop, and spit out impressive findings and differentials with the single Gestalt.

If the world’s greatest radiologists can do it this way, why can’t you?

Well, what if I was to tell you to avoid this expert radiologist’s approach? You might think I was crazy, even though it may be hazardous to your career! But this “Gestalt approach” is most likely the wrong one for you.

But why? Why does this Gestalt approach to films, used by expert radiologists, not work well for the neophyte radiologist? To answer this question, we will define Gestalt and explain why this approach can be dangerous for early radiologists. Then, instead, we will tackle why and how radiology residents should read films using the “segmental approach.”

Defining Gestalt

Let’s start by defining the principles of Gestalt. According to Wikipedia, these are “the idea that natural systems and their properties should be viewed as wholes, not as collections of parts.”

Radiologists use the Gestalt approach when they sense the findings and diagnosis without processing the individual steps. I like to think of the Gestalt approach like The Dog Whisperer, Cesar Milan. He can naturally sense the overall picture of a dog that others cannot. With this sixth sense, he can train dogs to do whatever he wants while mere mortals struggle to figure out exactly how to do what he does.

Why Avoid the Gestalt Approach When Starting?

Since you have not been practicing radiology for long, you will miss half the findings in the film. You don’t know what you don’t know. And, if you don’t look for a finding, you won’t mention it or find it. So, if you read a chest film and don’t know to look at the pulmonary arteries, you won’t find that case of pulmonary hypertension. The Gestalt approach does not allow for evaluating each of the individual sectors of the film to ensure you have looked at it.

How long have you been practicing radiology? At most, for residents, three or four years. Rarely is that enough time to build a network in your brain allowing you to look at a film rapidly once and then create a framework for arriving at a final impression of the study. You have not trained your eyes to search everything in the image in a short period. And, therefore, you will not catch everything.

Take it from me; the Gestalt approach is a fast way for a resident to look like a fool. When you review a case with another clinician, they will catch things you missed. What could be more embarrassing?

What Approach Should You Use?

Instead of the Gestalt approach, the beginner radiologist should utilize a segmental approach. What do I mean by that? The segmental system divides the film into individual parts. You then review the entire image until you have completed your search pattern. In essence, it is a glorified checklist.

In addition, the segmental approach can vary for each reader based on personal preference. For some, you may divide the chest film into quadrants. For others, on the chest film, you may look at the technique, the heart, the soft tissues, the bones, and the lungs. Whatever the pattern, it usually doesn’t matter except that you cover all bases. As a beginning radiologist, this approach will prevent you from missing critical findings. And you will look much more intelligent than the new radiologist that uses a Gestalt approach.

The Bottom Line About the Gestalt Versus Segmental Approach

The Gestalt approach does not work well for beginning radiologists unless they have a tremendous gift. Most learners cannot look at the whole to identify the abnormalities in each part. Instead, the new learner is more adept at looking at all the pieces to determine what went wrong with the whole. Therefore, until you have the experience to identify abnormalities with a glance rapidly, the Gestalt approach is a recipe for disaster.

So, create a great, all-inclusive search pattern to avoid missing individual findings. Who knows? Maybe someday you will become that great radiologist who uses that Gestalt approach!

 

 

 

Want to see the original Doximity version? Click on the following link!

Link to the Doximity Website Version

 

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Reading Imaging Studies On Our Clinical Colleagues

colleague

The Scenario

A clinical colleague walks up to you, and the following conversation ensues.

Clinician: Can you take a look at my chest film? I have had a cough for several weeks that won’t go away.

Radiologist: Sure. Let me take a look at the image.

The name of the clinician is on the computer, and the scan pops up on the screen

Clinician: Well, what do you think?

The radiologist stares intensely at the screen. Beads of sweat begin to form on his forehead as he sees a spiculated 6 cm left perihilar mass with adjacent interstitial changes and pulmonary nodules in the opposite lung. The clinician stares at the radiologist in front of the desk.

Radiologist: Well… Ummm…

Clinician: Well, what do you see?

By far, reading your fellow clinical colleague’s imaging studies has the potential to be one of the most stressful clinical situations as a radiologist. (as witnessed above) Even worse, the physician-patient may stand directly in front of you while looking at the films for the first time. God forbid we find something potentially lethal or unexpectedly harmful.

Over the years, similar scenarios have played themselves out several times. And, it’s not just me. It happens to most radiologists at some point in their careers, probably you as well. So, what do we do in these situations? Well, you guessed it. That is the theme for today’s post. Let me try to give you a few pieces of sage advice.

Take Time To Read The Study And Call The Clinical Colleague Later

Like I previously advised in prior posts such as Radiology Call- A Rite Of Passage, you are better off taking your time and going through your search pattern rather than being interrupted and making the wrong diagnosis. When a physician-patient stands right in front of you and stares at the screen, you direct your attention toward your emotions, leading to poor discrimination and interpretations. You are not doing justice to good clinical care.

I know. It is challenging to say to the physician-patient, “I can’t look at your images while in the room.” Instead, just say, ” I will look at your images later when I can make my best interpretation.” Most of the time, your clinical colleague will comply (But not always!). It indeed allows you, the interpreting physician, to have time to think about the films and diagnosis appropriately.

Don’t Beat Around The Bush

Your colleagues are physicians and generally know a bit about imaging/radiology. They will see if you are holding back a finding. So, regardless of whether you are on the phone or in person, you just need to tell them what you see. In radiology, however, most findings and impressions (even malignant-looking ones) can have numerous outcomes. In this situation, it is reasonable to say I think it may be x (a malignant diagnosis), but I have seen when it turns out to be y (a benign diagnosis). Of course, you don’t want to give false hope. But we, as radiologists, are rarely 100 percent correct! That gives you a little bit of an out.

Never Farm-Out This Responsibility To Another Radiologist!

Generally, there is a reason why this physician-patient comes to you to read their study. Maybe, they like your skills as a radiologist. Or perhaps, she sees you as a confidant and friend. But for whatever reason, this person came to trust you to read his film. It is never appropriate to shirk your responsibility to talk to the physician-patient by doling the obligation to another physician. It is part of your responsibility as a colleague and physician. Not to say, you cannot get help with the interpretation if complicated. But, you need to be the one that directly speaks to the physician-patient.

Be There As A Friend/Colleague

Finally, as radiologists and physicians, we are all interconnected to our fellow clinicians through the shared medical experience. It is essential to remain present as a friend and colleague to the physician-patient you diagnosed. Give the physician-patient your number to call if they have any additional questions. Commiserate over the diagnosis. Treat this person as you would any friend.

Treat A Colleague As We Would Want To Be Treated!

Our most demanding jobs as radiologists and clinicians are not the day-to-day interpretations of films and coming up with differential diagnoses. But instead, they are the problematic interactions that we may need to have at some point with our colleagues and friends. We need to relay the information to them about their images in an appropriate, correct, and thoughtful way. Even though there is no perfect way to do so, we must treat our colleagues as we want to be treated ourselves.